Ignatavicius: Medical-Surgical Nursing, 6th Edition

Which statement by a client with psoriasis indicates a need for further teaching? a. "At the next family reunion, I'm going to ask if any of my relatives have psoriasis." b. "I have to make sure I have this covered so I do not spread it to others." c. "I expect that these patches will get smaller when I lay out in the sun." d. "I should continue to use the cortisone ointment as the patches shrink and dry out."

ANS: B Psoriasis is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links, and the patches will decrease in size with ultraviolet light exposure.

How often will the nurse change a transparent film dressing for protection of a small, clean, lightly draining wound? a. Every 8 to 12 hours b. As soon as the dressing is dry c. When "strike through" has occurred d. When the seal breaks and exudate leaks

ANS: D Transparent film dressings on a clean base can be left in place for days, until the seal is broken and exudate leaks.

Which finding puts a client at greatest risk for wound infection? a. Client who is immunocompromised b. Client with a deep wound c. Client with reddened skin d. Client with a deep wound

ANS: A A compromised immune system puts a client at greatest risk for infection.

An African-American woman had a breast biopsy 1 year ago. The incision site is elevated, dark, and protruding. Which is the nurse's interpretation for these finding? a. The client has formed a keloid. b. There is a high probability that skin cancer has developed. c. The benign breast disease has undergone malignant transformation. d. Chronic inflammatory of deep infection has occurred.

ANS: A A keloid is a benign, noninfectious, overgrowth of a scar from an excessive accumulation of collagen and ground substance after skin trauma. Although anyone can form a keloid, the propensity is more common among people with dark skin. This is a benign condition.

Which client statement indicates a need for further discussion about the causes and treatment of acne? a. "There must be something else wrong here. Only teenagers get acne." b. "If I am careful not to squeeze the pimples, chances of scarring are reduced." c. "These pimples cleared right up when I was taking an antibiotic for bronchitis." d. "I should not use cortisone cream on it."

ANS: A Acne can occur at any age. The client is correct in stating that the pimples should not be squeezed and that cortisone cream should not be used.

A nurse notes that the client who has been using psoralens-ultraviolet A (PUVA) therapy for psoriasis for 1 month has darkening of the skin. Which is the nurse's best action? a. Documenting the finding b. Instructing the client to reduce the dose c. Instructing the client to drink more water d. Instruct the client to apply cortisone cream

ANS: A Darkening of the skin is an expected and normal response to the PUVA therapy. No other intervention is necessary.

The home care client with a leg wound is unable to climb stairs to the second floor where the bathtub is located. Which is the nurse's best intervention? a. "I'll show you how to use a 35-mL syringe to cleanse the wound." b. "It is not necessary to clean this wound because it is not infected." c. "You can use the kitchen sink and clean tap water for this purpose." d. "You will have to come to the hospital each day for hydrotherapy."

ANS: A Mechanical débridement can be accomplished using the forceful ejection of tap water from a 35-mL syringe. Soaking in a tub is not essential. The client does not have to travel to the hospital.

Which client is receiving appropriate treatment? a. A client with an ulcer and slight necrosis receiving whirlpool treatment b. A client with a draining sacral pressure ulcer receiving whirlpool therapy c. A client with sunburn and erythema soaking in warm water for 20 minutes d. A client with urticaria instructed to take warm showers twice a day

ANS: A Necrotic tissue should be removed so that healing can take place. The whirlpool treatment can gently remove the necrosis. A draining wound would not be treated with whirlpool therapy. Warm water would not be recommended for a client with erythema. A client with urticaria would be instructed to use cool water to decrease inflammation and itching.

Which intervention will best assist the client with pruritus? a. "Avoid activities and environments that increase perspiration." b. "Drinking alcoholic beverages will decrease stimulation of the itch receptors." c. "Wear clothing to keep the skin warm." d. "Avoid immersing the affected areas in water."

ANS: A Pruritus is exacerbated by poor skin hydration, increased skin temperature, perspiration, and vasodilation. Drinking alcoholic beverages will further dehydrate clients. Warm clothing will vasodilate, adding to dehydration. Warm baths are recommended, with lotion applied immediately afterward.

The client who has had a rhinoplasty is swallowing frequently and belching. Which action will the nurse take? a. Notifying the surgeon b. Raising the head of the bed c. Assisting the client with liquids d. Continuing to assess

ANS: A Repeated swallowing followed by belching after rhinoplasty is a sign of postnasal bleeding. This sign should be reported immediately to the surgeon.

Which client admitted to the hospital will be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus (MRSA)? a. The client admitted from a long-term care facility with furuncles and folliculitis b. The client with a leg cut from a motorcycle crash c. An adolescent with a rash noticed after a wrestling match d. A client transferred from a surgical stepdown unit with an elevated white count

ANS: A The client in long-term care and other communal environments is at high risk for MRSA. The presence of furuncles and folliculitis is also an indication that MRSA may be present. A client with an open wound from a motorcycle crash would have a potential to develop MRSA, but no signs are visible at present. A client with an elevated white count has a potential for an infection, but should be at lower risk for MRSA than the client admitted from the communal environment.

An older client is observed scratching and rubbing white ridges on the skin between her fingers, on her wrists, in the axillae, and around her waist. Which is the nurse's priority intervention? a. Placing the client in a single room b. Administering an antihistamine c. Assessing for allergies d. Applying cold compresses

ANS: A The client's presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. Cold compresses would not be indicated and this is not an allergic manifestation.

Which nursing intervention is best for the nurse to use to enhance healing of a 1-week-old partial-thickness wound? a. Using papain-urea (Accuzyme) cream as ordered b. Restricting the client's fluid intake c. Covering the wound with an airtight dressing d. Applying hydrocortisone cream as ordered

ANS: A The presence of necrotic tissue retards epithelialization and granulation development. Accuzyme is a cream that removes necrotic tissue. Restricting fluid and covering the wound will deprive the new tissue of nutrition and will not enhance healing. Hydrocortisone cream may decrease itching but will not enhance healing.

A nurse observes a small opening that is draining purulent material on the skin over the trochanter area of a bedridden client. Which is the nurse's next best action? a. Probing for a larger pocket of necrotic tissue b. Applying a transparent film dressing c. Measuring the reddened area on the skin surface d. Applying alginate dressing daily

ANS: A This "hidden" wound may first be observed as a small opening in the skin through which purulent drainage exudes. Applying a transparent film dressing would not help this type of wound to heal. Measuring the reddened area would not assist in determining the actual size of the wound, because there is internal damage. Alginate dressings could not be applied if the area were not opened.

Which preventive measure should be used for older adults to prevent skin lesions? (Select all that apply.) a. Using a lift sheet when moving client in bed b. Avoiding tape when applying dressings c. Avoiding any type of restraining device d. Avoiding whirlpool therapy e. Using loose dressing on all wounds f. Applying dressings only when wounds are draining

ANS: A, B Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the skin won't tear. Restraining devices may need to be used, but they should not be applied tightly. There is no contraindication to using whirlpool therapy for the older client.

The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which interventions are appropriate? (Select all that apply.) a. Placing a small pillow between bony surfaces b. Elevating the head of the bed to 45 degrees c. Limiting fluids and proteins in the diet d. Using a lift sheet to assist with repositioning e. Repositioning the client who is in a chair every 2 hours f. Keeping the heels off the bed surfaces g. Using a rubber ring to decrease sacral pressure when up in the chair

ANS: A, D, F A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and sheer, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head of the bed elevation more than 30 degrees increases pressure on the pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.

Which client is being treated effectively? a. Client with a transparent film dressing on a heavily draining wound b. Client with an alginate dressing on a heavily draining wound c. Client with a wet to dry dressing on a heavily draining wound d. Client with an Accuzyme dressing on a pink wound with no drainage

ANS: B Alginate is a type of dressing that is highly absorbent. A transparent film would not soak up the drainage, a wet to dry dressing is not for heavily draining wounds, and Accuzyme is for the débridement of necrotic tissue, and is not needed on a pink wound without drainage.

Which is the priority nursing diagnosis for the client going home with a surgical wound on the coccyx that is to heal by second intention? a. Acute Pain b. Risk for Infection c. Disturbed Body Image d. Risk for Deficient Fluid Volume

ANS: B Any wound left to heal by second intention is an open wound and is at risk for infection. Usually, within 2 days after the surgery, discomfort is minimal and the wound is not draining sufficiently for the client's fluid balance to be deficient. The client could have a disturbed body image in this situation, although wounds on the coccyx are not visible to the public. However, the priority in this situation is to prevent infection.

Which precaution will the nurse teach the client with urticaria who is prescribed to take diphenhydramine (Benadryl)? a. "Avoid sun exposure." b. "Avoid alcoholic beverages." c. "Avoid aspirin or aspirin-containing drugs." d. "Avoid weight gain."

ANS: B Benadryl is an antihistamine that will decrease itching. For most people, diphenhydramine causes drowsiness. This side effect is intensified when alcohol also is consumed, placing the client at increased risk for injury and falling. Aspirin will not interact with this medication. Weight gain and sun exposure should not affect the administration of the drug.

The client has frostbite on one cheek. After the frostbite has thawed, a few small blisters appear in the area. Which action will the nurse take? a. Notifies the health care provider b. Leaves the blisters intact c. Applies ice or cold compresses to the area d. Breaks the blisters and applies a topical antibiotic

ANS: B Blisters are left intact as a protective barrier to the injured skin beneath. Ice or cold compresses could extend the injury. It is not infected and a topical antibiotic is not necessary. The blisters should not be broken.

Which nurse most was infected by a client? a. The nurse with an oral lesion determined to be herpes simplex virus 1 (HSV1) infection b. The nurse with herpetic whitlow of the fingertip c. The nurse with herpes zoster involving the right side of the body d. The nurse with postherpetic neuralgia

ANS: B Herpetic whitlow is a form of herpes simplex infection that occurs in health care personnel who have come into contact with viral secretions. This can be spread to other clients as well, and precautions must be taken. HSV1 infection is most likely a recurring cold sore. Herpes zoster is caused by the reactivation of a virus dormant in the body. Postherpetic neuralgia occurs after an outbreak of herpes zoster and is not contagious.

Which statement made by the caregiver of a home care client indicates a need for clarification regarding pressure ulcer prevention and treatment? a. "I help him shift his position every hour when he sits in the chair." b. "I massage his tail bone every morning when he gets up because it is red." c. "I apply lotion to his arms and legs every evening because they are so dry." d. "He drinks a nutritional supplement between meals to maintain his weight."

ANS: B Massage of reddened areas over bony prominences such as the coccyx, or tail bone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers.

Which question will the nurse ask to determine a possible trigger for the worsening of a client's psoriatic lesions? a. "Have you eaten a large amount of chocolate lately?" b. "Have you been under a lot of stress lately?" c. "Have you used a public shower recently?" d. "Have you been out of the country recently?"

ANS: B Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis.

On assessment, the nurse notes a wound on the coccyx that is 3 2 2 cm. The epidermal and some of the dermal tissues are gone. The client reports pain when the nurse probes the wound with a cotton swab while assessing for undermining. The nurse charts this as what stage? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

ANS: B The criteria meet the definition of a stage 2 pressure sore.

Which is the priority nursing intervention for the client during the first 24 hours after a skin graft procedure? a. Monitoring for detection of hemorrhage b. Monitoring of graft site to assess "take" of the newly grafted skin c. Repositioning the client every 2 hours to prevent pressure ulcer formation d. Performing interventions to prevent contracture development

ANS: B The most serious common complication in the early postoperative period after skin grafting is failure to engraft. Hemorrhage is not a common complication post-skin grafting. Pressure ulcer formation and contracture development would not occur quickly after grafting.

Which strategy will best prevent the spread of a fungal infection that is beneath a client's breasts? a. Moving the client into a private room b. Washing hands after caring for the client c. Wearing gloves when providing personal care d. Applying cortisone cream to lesions

ANS: B The organism that causes this infection lives on the skin of most adults. Good handwashing is all that is needed to prevent its spread to other people, although the client will need medication to clear her active infection and moisture management to prevent its recurrence.

Which dietary choice is best for a client who has been identified as being at risk for imbalanced nutrition and formation of pressure ulcers? a. Low-fat diet consisting primarily of whole grains and cereals, with vitamin supplements b. High-protein diet with vitamins and mineral supplements c. Vegetarian diet with increased caloric supplements d. Low-fat, low-cholesterol, low-carbohydrate diet

ANS: B The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes. A vegetarian diet would not provide fat and high levels of protein.

When changing the dressing on a partial-thickness wound, a nurse observes small, pale pink bumps within the wound bed. Which is the nurse's best action? a. Removing the bumps with a sterile scalpel b. Documenting and continuing current treatment c. Cleaning the wound vigorously, wiping off the bumps d. Culturing the wound and placing the client on contact precautions

ANS: B The small, pale pink bumps are granulation tissue characteristic of new capillary bed growth, an indication of proper wound healing. The nurse should continue current treatment and assessments. Attempting to remove the bumps in any way can interfere with healing.

A client has numerous skin lesions. Which one will the nurse evaluate first? a. Beige freckles on the backs of both hands b. Irregular blue mole with white specks on the lower leg c. Large cluster of pustules in the right axilla d. Raised, tubular, white, snake-like areas on the inner aspects of the wrists

ANS: B This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the potentially cancerous lesion first.

In preparation for a client being admitted with herpes zoster, what will the nurse do? (Select all that apply.) a. Prepares a room for reverse isolation b. Inventories the staff for a history of or vaccination for chickenpox c. Checks the admission orders for analgesia d. Chooses a roommate who also is immunosuppressed e. Ensures that there are gloves in the room

ANS: B, C, E Herpes zoster (shingles) is caused by a reactivation of the same virus, varicella zoster, in clients who have previously had chickenpox. Anyone who has not had the disease or has been vaccinated for it is at high risk of getting chickenpox. It is a disease of immunosuppression, so no one who is immunosuppressed should be in the same room. It is best to put this client in a private room. Use of gloves and good handwashing are sufficient to prevent spread. It is very painful and requires analgesia.

When getting a client up in a chair, the nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which is the nurse's best action? a. Turning the mattress overlay to the opposite side b. This is expected occurrence c. Applying a different pressure-relieving device d. Reinforcing the overlay by placing cushions between the mattress

ANS: C "Bottoming out," as evidenced by the deep imprints in the mattress overlay, indicates that this device is not appropriate for this client and a different device or strategy should be implemented to prevent pressure ulcer formation.

Which client will the nurse see first to evaluate for wound infection? a. The client with a negative blood culture b. The client with thin serous drainage c. The client with a white blood cell count elevation d. The client with a decrease in wound size

ANS: C A client with an elevated white count should be evaluated for sources of infection. Thin drainage, decrease in wound size, and negative cultures are not indications that the client may have an infection.

Which client's wound will the nurse recommend for surgical management? a. Client with a stage II pressure ulcer with granulation b. Client with a stage III pressure ulcer with a foul odor c. Client with a stage IV pressure ulcer with necrotic tissue d. Client with a stage III pressure ulcer with decreased blood flow

ANS: C A wound with necrotic tissue needs to be débrided. This can be done surgically. A client with a deep pressure ulcer or wound may also be a candidate for a muscle flap to close it. However, if there is not good blood flow to the area, the client would not be a candidate for grafting. Granulation is an indication that wound healing is occurring and no surgical intervention is necessary. A wound with a foul odor should be evaluated for infection by culturing the exudates

Which dressing choice will the nurse make to protect a heavily draining deep pressure ulcer? a. Wet to dry gauze b. Dry cotton gauze c. Alginate packing, dry gauze cover d. Hydrocolloidal transparent film cover

ANS: C Alginates are highly absorbent materials that do not damage healthy tissue. They require a top dressing to stay in place. Because this wound is draining heavily, this is the best choice. A wet to dry gauze is not used for this type of ulcer. A transparent dressing would hold in the drainage. Dry cotton gauze would quickly become saturated.

Which question is most important for the nurse to ask the family members of the client with herpes zoster? a. "Have you ever had measles?" b. "Have you ever had mumps?" c. "Have you ever had chickenpox?" d. "Were you vaccinated against polio?"

ANS: C Herpes zoster is caused by the same virus that causes chickenpox and is contagious to those who have not had chickenpox or who have not been vaccinated against it.

Which is the most important question to ask a young adult woman about to begin taking isotretinoin (Accutane)? a. "Do you spend a great deal of time in the sun?" b. "Have you or any member of your family ever had skin cancer?" c. "Which method of contraception are you using?" d. "Do you drink alcoholic beverages?"

ANS: C Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated and strict birth control measures must be used during therapy.

Which characteristic regarding leprosy is true? a. There are only a few cases found in underdeveloped countries. b. Affected clients must be confined away from the general population. c. Continuous treatment with antibiotic agents is necessary. d. Because the disease has an autoimmune basis, the most effective treatment of leprosy involves immunosuppressive drugs.

ANS: C Leprosy is a communicable disease caused by mycobacteria. It is present in most areas of the world, including the United States. It can be controlled with antibiotic therapy and does not require the client to be isolated.

For which client would the nurse first prioritize care? a. Client with folliculitis b. Client with furuncles c. Client with cellulitis d. Client with stage II ulcer

ANS: C The client with cellulitis has a generalized infection with Staphylococcus or Streptococcus that involves deep connective tissue. The client with folliculitis has a superficial infection of the upper portion of the follicle and the client with furuncles has a deeper infection in the hair follicle. A client with a stage II ulcer with no infection is less of a priority.

Which intervention will the nurse perform first for a client with pruritus? a. Assessment of vital signs b. Elevation of legs c. Instructing client not to scratch d. Administration of pain medication

ANS: C The first intervention is to instruct the client not to scratch. Scratching can lead to infection and open sores. The client could also soak in cool water, take antihistamines, or apply lotion.

The client has an epidermal cyst behind the right ear. Why is surgical removal of this cyst indicated? a. Most cysts become chronically infected and painful. b. Epidermal cysts have a high rate of transformation to cancer. c. The client's glasses press against the cyst and cause discomfort. d. Unless surgically removed, the cyst could increase in size and compromise the client's hearing.

ANS: C Therapy to remove an epidermal cyst is rarely indicated unless the client prefers that it be removed

In assessing a client's wound, which finding assists the nurse in determining that the wound is infected? (Select all that apply.) a. The wound is open. b. The wound has granulation tissue. c. The wound is inflamed. d. The wound has an odor. e. There is heavy exudates. f. Necrotic tissue is present.

ANS: C, D, E A wound that is open can be contaminated, but not necessarily infected. Granulation tissue is a healthy response. The presence of inflammation, odor, and exudate is an indication that the wound should be cultured to determine infection.

A client presents with a pressure ulcer on the ankle. Which is the first intervention that the nurse will implement? a. Blood tests for albumin, prealbumin, and total protein b. Wound culture c. Elevation of the foot d. Assessment of pulses, skin color, and temperature

ANS: D A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler if unable to palpate with his or her fingers. Elevation of the foot would impair the ability of arterial blood to flow to the area. Wound cultures are done after determining that there is drainage, odor, and other risks for infection. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done.

A nurse determines a client as having a Braden scale score of 9. Which is the nurse's best intervention related to this assessment? a. Encouraging the client to lay as still as possible in bed b. Reassessing the client weekly c. Increasing the client's fluid intake daily d. Consulting with the health care provider about increased interventions

ANS: D A score of 11 or less on the Braden scale indicates severe risk for pressure ulcer development in terms of decreased sensory perception, exposure to moisture, decreased independent activity, decreased mobility, poor nutrition, and chronic exposure to friction and shear.

Which instruction is best for the nurse to teach the client who has a furuncle in his axilla? a. "Apply cortisone cream to reduce the inflammation." b. "Squeeze the lesion until it opens and all pus and other material are removed." c. "Keep your arm down against your side to close off the area and prevent spread." d. "Wash with antibacterial soap and apply warm compresses and antibiotic cream."

ANS: D Cortisone cream reduces the inflammatory response but increases the infectious process. Squeezing the lesion may introduce infection to deeper tissue and cause cellulitis. Keeping the arm down increases moisture in the area and promotes bacterial growth. Cleansing and topical antibiotics can eliminate the infection. Warm compresses increase comfort and open the lesion, allowing better penetration of the topical antibiotic.

Which nursing intervention will best assist a client who is bedridden to keep skin intact? a. Keeping the skin dry b. Repositioning the client every 2 hours c. Using a foam mattress pad d. Using a lift sheet to move the client up in bed

ANS: D Friction forces are generated when the client is dragged or pulled across bed linen. Using a lift sheet will prevent friction. Keeping the skin dry will not keep skin intact. Research actually recommends turning the client every 20 minutes to minimize vasoconstriction from dependency. A foam mattress will not significantly decrease pressure to an area.

A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the perimeter, and bone is exposed. Which is the nurse's best action? a. Document as a stage I pressure ulcer and apply a transparent dressing. b. Document as a stage II pressure ulcer and start wet to dry gauze treatments. c. Document as a stage III pressure ulcer and start antibiotic therapy. d. Document as a stage IV pressure ulcer and prepare the client for possible surgical intervention.

ANS: D The U.S. Department of Health and Human Services pressure ulcer criteria categorize a stage IV ulcer as one in which skin loss is full thickness, with extensive destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures. When the bone of the trochanter area is visible, there has been tissue loss that includes muscle loss. A potential intervention is débridement of the necrotic tissue and a possible graft.

The client has dry skin and a history of cardiovascular disease. Which is the best intervention for the nurse to teach the client? a. "Wear pajamas to cover your legs at night." b. "Avoid wearing stockings." c. "Increase your fluid intake to 3 L/day." d. "Bathe in warm water and then apply lotion immediately."

ANS: D The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Covering the legs at night will not increase moisture. Increasing fluid intake to 3 L/day would not be recommended for a client with a history of cardiovascular disease. Stockings may dry the skin, so the best intervention is to keep moisture in the skin with lotion.

Which client is at greatest risk for pressure ulcer development? a. Client who has pneumonia b. Client who requires assistance with ambulation c. Older client with hypertension d. Incontinent client with limited mobility

ANS: D The client who is confined to a chair has the most risk factors. Being immobile and incontinent are two significant risk factors for the development of decubiti.

A client presents with pruritus of the lower extremities. Which nursing assessment is most appropriate? a. Blood draw to determine electrolyte imbalance b. Weight to determine fluid retention c. Microscopic evaluation to determine presence of fungus d. Surface evaluation for presence of dry skin

ANS: D The client with pruritus often has dry skin as a stimulus. The nurse should evaluate this first. If present, the client should be instructed in how to treat this.

The home care nurse is visiting an older adult client who has diabetes and "skinned his shin" yesterday. There is an intact scab over the abrasion and the skin around it is red, warm, and hard. Which is the nurse's best action? a. Teaching the client how to apply cold compresses to the area b. Lifting an area of scab to see if any exudate can be expressed c. Measuring the length and width of the red area d. Calling the health care provider for a prescription to treat cellulitis

ANS: D The clinical manifestations indicate cellulitis, a bacterial tissue infection that can spread rapidly and deeply, especially in a client who is diabetic. Cold compresses would not be effective in allowing the lesion to heal.

A nurse inspects the site where a client's basal cell carcinoma has been treated with cryosurgery and finds that the area is red, with a blister in the center. Which action will the nurse take? a. Culturing the site b. Notifying the surgeon c. Applying hydrocortisone cream d. Continuing to assess

ANS: D This skin reaction is the expected and normal response to cryosurgery. No other intervention is necessary other than continued assessment.

Which statement made by the client indicates correct knowledge about the causes and treatments of common warts? a. "Washing my hands more frequently will prevent the warts from coming back." b. "I will have to be careful because warts increase the risk for skin cancer." c. "Surgical removal of the warts is the best treatment." d. "Because warts are caused by a virus, they can occur anywhere on my body."

ANS: D Warts are caused by a virus, are not precancerous, can occur anywhere on the body, are not related to poor hygiene, and may recur after treatment.